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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -- - ------------------------------ Permit No: <br /> ------ ----- -- <br /> (Complete in Triplicate) <br /> ---------------------------------------- ---------------- <br /> This,Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> 'described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> f,cfzS;v <br /> JOB ADDRESS/LOC ION - --- --- 01 J- �� ¢ �y�� ------------------------ <br /> ---------------CENSUS TRACT -------------------------- <br /> Owner's <br /> -- - --------------------Owner's Name -d' ------------------------------------------- Phone <br /> Address �a --f14----------- Cit s. '------------------------------------------•- <br /> Y <br /> Contractor's Name ---_ -fir - --- -- -_--_-_--'-��-�---_,� ^�-----.License # -1 ,3�------ one .-------------- ---.- <br /> Installation will serve: Residence [Apartment House ❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:------ ----- Number of bedrooms-------Garbage Grinder --.-.--.-.-- Lot Size --------------------------- ----------------- <br /> Water Supply: Public System and name ---------------------------------•-•---------------------------------------------------- -----------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt F] Clay F1 Peat E] Cl <br /> Sandy Loam ay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material If yes, type ---------------------------- <br /> N(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth -----------------._---..-. <br /> Capacity ---- --------------- Type ----- -------------- Material---------------------- No. Compartments ------ -------- ------ <br /> Distance to nearest: Well --------------------------•--------•Foundation --------------------- Prop. Line ---------------------- <br /> LEACHING LINE [ ] No. of Lines - ---------------------- Length of each line_ -- Total Length -_---.------_---..---.---. <br /> 'D' Box .----------- Type Filter Material --------------------Depth Filter Material -- ----------------------------------------- <br /> Distance to nearest: Well ------------------------- Foundation ------------------------ Property Line --------.-------.-.----- <br /> SEEPAGE PITDe th <br /> [ 1 p ---------- Diameter ---------------- Number --------------------- Rock Filled Yes ❑ No � <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well - --_-------------------------Foundation -----------------— Prop. Line ---------.------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit r# -------------------------------------------- Date -_-------------_------_-----_-----) <br /> SepticTank (Specify Requirements) -JJff ------------------------------------------------------------•---------------------------.------------------------- 4 <br /> Di s osai Field (Specify,. Re Requirements) et - --_ _. � fi <br /> � -q _ i - �+---t-------- <br /> ------------- <br /> ------- <br /> !'"�'"` - �E ---------/0-0------- <br /> -.�.,.. �-----------------------------------------------------� ------------------------------------------------------------------------ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to becomr- 7 <br /> to Workman's Compensation laws of California." <br /> Signed - --- Owner <br /> BY - Title `` " S._ G✓'tr- ---- ------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- -- - ---------------------- DATE -V-".774- ! ------------------- <br /> BUILDING PERMIT ISSUED jr <br /> DATE <br /> ADDITIONALCOMMENTS ------------ ----------------- -- ---------------------------------------------------------------------- -----------------------=--------------------------- <br /> ------------------- ---------------------------------------- -------------------------------------------------------- ----------------------------------------------------------------------------------- <br /> , , <br /> ------------------ ------ -- ----------------------------------------------------------------------------- - ---- - - - - =------- <br /> Final Inspection by: --------------------------------- Date f � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br /> f <br />